Pyloric stenosis Quiz: Ace Your Exams

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A 4-week-old boy was transferred from an outside hospital to a pediatric tertiary care center yesterday with a suspected diagnosis of pyloric stenosis based on history and physical exam. The prior emergency department physician reported that the patient was initially tachycardic and hypotensive, and his parents stated that he had not voided in at least 12 hours. IV access was obtained, IV fluid resuscitation was initiated, and his hemodynamics began to improve prior to transfer. After transfer to the pediatric hospital, an abdominal ultrasound was obtained and findings confirmed the diagnosis of pyloric stenosis. Today, his temperature is 36.8 °C (98.2 ºF), pulse is 140/min, blood pressure is 70/40 mmHg, and SpO2 is 100% on room air. Laboratory results from this morning are shown below. He has had 2 wet diapers in the last 12 hours, no bowel movements, and no further episodes of emesis. He remains nil per os (NPO) with weight-based maintenance IV fluids running. What is the best next step in management?

Laboratory Value    Result    Reference Range    
Serum Chemistry         
Sodium     136 mEq/L    133-140 mEq/L    
Potassium     4.1 mEq/L    4.1-5.8 mEq/L    
Chloride    95 mEq/L    96-106 mEq/L    
CO2     33 mEq/L    20-26 mEq/L    
Creatinine     0.31 mg/dL    0.1-0.4 mg/dL    
BUN    9 mg/dL    2-19 mg/dL    
Venous Blood Gas         
pH     7.48    7.34-7.44    
PCO2    47 mmHg    40-50 mmHg    
PO2    35 mmHg    25-47 mmHg    
HCO3    38.2 mmol/L    22-26 mmol/L    

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